COR051

INDIVIDUAL STUDENT MEMBERSHIP APPLICATION FORM

Individual Student applicant Information:
Surname / First Names
Title / Mr, Ms, Miss, Prof, Dr, / Designatory / e.g. BSc, CEng, MIMF, Secretary
Country / Business
Fax No. / Home No.
Mobile / Date of Birth
Email / Email Work
Physical
Address / Postal
Address
Code / Code
Employer Information:
Company / Dept.
Position / Acc Email
Work No. / Fax No.
Physical
Address / Postal
Address
Code / Code
Which event would be of interest to you? (Please Tick)
Conferences / Technical Evenings / How to Days / Golf Events / Fishing Events / Plant Visits
Annual Dinners / Other - Specify
How would you best describe your business? (Select only one)
SERVICE PROVIDER / Cathodic Protection / CONSTRUCTION/MANUFACTURER: / ASSOCIATION: / General Interest:
Application / ASSET OWNER/END USER:
Corrosion Consulting
Labs and Testing / SET SKILL / Chemistry / SUPPLIER / Cathodic Protection Products
Quality Control / Metallurgy / Application Products
Training / Engineering / Coating Material
OTHER – Specify below: / OTHER – Specify below / GENERAL – Specify below:
Which region would you select? (Please Tick)
For mailing purposes, we will allocate you to your home region unless otherwise specified.
Gauteng / Kwa Zulu Natal / Western Cape / Other - Specify
APPLICANT'S DECLARATION: (See the By-laws to the Constitution)
I do hereby apply to be admitted as an Individual Student Member of the Corrosion Institute of Southern Africa, and I do solemnly and sincerely declare that in the event of my election as an Individual Student Member of the Institute, I will at all times observe the provisions of the constitution and the By-laws thereof and will conduct myself honourably in the practice of my profession, and to the utmost of my power will maintain the dignity and welfare of the Institute, by adhering to the code of ethics as defined in the Constitution.
YES / NO / Email notification allowed / YES / NO / SMS notification allowed
Name / Date
Signed at / Signature

Version: 1Revision Date: May 2017Page 1 of 2

Annexure A

MEMBERSHIP FEES FOR 2017/2018

ANNUAL SUBSCRIPTIONS

(Note: New Members include once off admin fee)

CATEGORY / FEE / Including VAT
Individual member / R484.21 / R552.60
Fellow member / R605.00 / R690.00
Student Member / R181.58 / R207.00
Universities / R2382.46 / R2716.00
Company member / R3629.82 / R4138.00
Honorary Life Member / Nul / Nul
Retired Member / Nul / Nul
CATEGORY / FEE / Including VAT
Once off Admin Fee for New Members Only / R275.44 / R314.00
Banking Details:
Corrosion Institute of Southern Africa
Bank:First National Bank
Branch: Carlswald
Branch code:250 117
Account No.:5921 0034 002 / Payment method:

Electronic Transfer – proof attached
Cheque enclosed for R ______
Receipt of payment will be acknowledged